Racial disparity in maternal deaths persists

Lawmakers seek study of why black women are 4 times as likely to die


WASHINGTON -- Eight months pregnant, Deborah Edwards smoothed a thin hospital gown over her belly, nibbled at a graham cracker and ticked off the reasons she had spent a week confined to the maternity ward of George Washington University Hospital.

At 42 she is, in medical parlance, of "advanced maternal age." She had no prenatal care until last month: After 20 years of marriage and two adopted children, she had no idea she was pregnant. She weighs 208 pounds, up from 196. She has diabetes, which puts her baby in danger. And her high blood pressure has worsened into pre-eclampsia, a condition that could kill her if it is not carefully monitored.

"I'm concerned," she said, "but I'm not worried. I know I'm being cared for."

But Edwards possesses another characteristic that statistically puts her at risk during delivery: She is black.

At a time when the Clinton administration has set a goal of eliminating racial disparities in health by 2010, medical experts are struggling to understand one of the most glaring, and least talked about, disparities of all: death in childbirth.

In a study made public this spring, the Centers for Disease Control and Prevention in Atlanta reported that black women in the United States were nearly four times as likely to die during delivery, or shortly thereafter, as white women. The disparity, which has remained about the same for four decades, holds true even for women who, like Edwards, are middle class and have health insurance.

The findings -- coupled with the awareness-raising efforts of a Connecticut man whose wife died in childbirth -- have renewed interest among scientists and legislators in a problem that many people thought no longer existed.

A bipartisan issue

The issue is also making for strange political bedfellows in Washington. On Tuesday, Reps. Nita M. Lowey, a New York Democrat, and Jo Ann Emerson, a Missouri Republican, convened a panel of doctors, women's health advocates and CDC officials to discuss maternal mortality and garner support for a bill, introduced in June, that would provide additional federal money to study it.

"We are trying to get together, whether Democrat or Republican, pro-choice or pro-life, white or black," Lowey said, "to get the best research, the comprehensive data, the right programs."

Dying in childbirth, in this country, is extremely rare. But several facts trouble federal health officials. First, while infant mortality has declined steadily over the last decade, maternal deaths have remained unchanged, and experts think as many as 70 percent could be prevented. Second, the 4-to-1 racial disparity in maternal deaths is among the widest gaps in public health.

In 1997, the most recent year for which statistics are available, 327 women died in childbirth in the United States. When the CDC examined deaths over a nine-year period, from 1987 to 1996, it found that one black woman died for every 5,102 who gave birth; among white women, the figure was one in 18,868. While the deaths are few, said Dr. David Satcher, the U.S. surgeon general, "the disparity is important."

`A certain standard' in U.S.

"If we were comparing black women in this country with women in Tanzania," Satcher said, "we would be talking about how great we are doing. We are not. In this country, we have a certain standard of expectation about the risk of women dying in pregnancy, and black women are off the scale right now."

The reasons for this are varied, and not well understood. Black women are more prone to obesity, hypertension and diabetes, conditions that can complicate pregnancy. Poverty plays a role, as does the drug and alcohol abuse that sometimes goes with it, experts say. So, too, does poor prenatal care.

Yet black and white women generally suffer the same types of complications. For every maternal death, CDC officials say, 1,600 women are admitted to hospitals for pregnancy complications that are not related to delivery.

"The paradox that we have is that mortality is about four to five times higher among blacks, but morbidity, or complications, are only 1.5 times higher," as measured by hospital admissions, said Dr. Hani Atrash, chief of the CDC's pregnancy and infant health branch. "What worries me most is that it may be true that blacks and whites have the same rate of complications," he said, but blacks may seek medical care "at a later stage and with more serious conditions, and therefore their mortality is higher."

Officials at the CDC, as well as at the American College of Gynecologists, are pressing state health officials to resurrect the practice of performing maternal death reviews. Dr. Jeffrey C. King, who is leading the effort for the obstetricians' group, said only 25 states conduct in-depth examinations when a pregnant woman dies.

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